1. Chest Pain and Cardiac Emergencies 2015

4. Chest Pain and Cardiac Emergencies WelcomeChest PainCertaintySimulation

5. Introduction Chest Pain is common – 6 potentially lethal causes to remember – Traditional approach (*full Hx) may be suboptimal Assessment and Management should focus on – ABCDEFG and ECG – IV access, M.O.N.A. (may not be right anymore) – Senior review (#8500/mobile or Medical Registrar)

6. Approach – Traditional vs. Emergency Life ThreatsSerious Causes Benign Causes (Common)

7. Lethal Causes Myocardial Infarction (MI) Pulmonary Embolism (PE) Aortic Dissection (AD) Pneumothorax (Tension Pneumothorax) Pneumonia and Sepsis Oesophageal Perforation

8. Myocardial Infarction and the Acute Coronary Syndromes ECG

9. ECG 1

11. Acute Coronary Syndrome Assessment

12. Assessment – DETECT ABC approach Pitfalls – Elderly Patients are often pain free – MI patients may have NO risk factors

13. Acute Coronary Syndromes (ACS) Acute Coronary Syndromes STEMI (30%) NSTEMI (25%) UAP (35%)

14. Atypical = Typical

15. Acute Coronary Syndrome Management

16. Management – MONA Morphine – 0.1mg/kg IV and reassessment Oxygen – titrated to 94% (no longer routine) Nitrate – with care (avoid in RV infarction) Aspirin – have a high threshold for not giving – low NNT and good safety profile Other (ABCDEFG) – ACE Inhibitor, β Blockers, Clopidogrel & Prasugrel – Don’t ever forget glucose (BSL) – Fluids (often required in RV infarction)

17. Management DOCUMENTYOUR PLANCLEARLY

18. Referral – “ISBAR” Page 8500 and/or Cath Lab Team (STEMI) Your Registrar Consultant (in hours) Medical Registrar (out of hours) Intro - I am Andrew the Intern covering A5C Situation and Background - I have Mrs Smith who is in hospital with abdominal pain that was thought to be from Gallstones – she now has Chest pain & ST Elevation in AVF, II and III Assessment – obs Response – review COMMUNICATEEFFICIENTLYAND CLEARLY

19. Management Resuscitation, Specific (MONA) and Supportive Disposition – Catheter Laboratory – Cardiac Unit (A5a, A5c) – CCU (A5b) – Cardiothoracics (C3c and D3c) – Respiratory Ward - PE and Pneumothorax (B5a) – ICU (E3a and E3b) – Home & follow up (e.g. EST, Cardiac CT, MIBI, Echo)

20. Chest Pain Risk Stratification and State Policy

24. ALL PROTOCOLSARE ON EDINTRANET

25. Other Causes of Chest Pain

26. Pulmonary Embolism

27. Aortic Dissection Uncommon 5/100,000 Overall Mortality is 27% in hospital, 1% per hour and >90% untreated Ratio of MI to Dissection is 3000:5 (so it i s often missed and treated as MI) Risk Factors – Hypertension, Cardiothoracic Surgery, Collagen Vascular Disease Stanford – A & B (‘A’ proximal involvement) CXR and BP both arms have limited value!

28. Pneumothorax

29. Arrhythmia Recognition and Management

30. Has the patient arrested? Perfusion No Pulse ALS Algorithm Pulse Assessment of Stability

31. Is the patient stable? Are there any adverse signs? Stability and Adverse Signs Extremes of Heart Rate *Blood Pressure and Perfusion Chest Pain Signs of Acute Heart Failure

32. Arrhythmias The Mantra / Approach – How is the patient? What is the Cause? – IV, O2, Monitor – Call for assistance Assessment of Rhythm – Assessment of Pulse and Adverse Features – Narrow Complex vs. Broad Complex – Regular vs. Irregular – Slow, Fast vs. Very Fast

33. Causes of Bradycardia/Tachycardia? Drugs Ischaemia Electrolytes

34. Take Home 6 lethal causes ‘Atypical = Typical’ (Non-cardiac = Non-cardiac) A – G approach Serial ECGs Call for senior help Call for help (ALS team) for patients with adverse signs including refractory chest pain, shock, extremes of heart rate and cardiac failure